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Local serious case reviews (SCRs) (now Safeguarding Adults Reviews (SARs)) may be held in England when a vulnerable adult dies or is harmed or at risk of being so, and local agencies may not have responded to the abuse or neglect. The purpose of this paper is to present findings from a documentary analysis of these reviews to ascertain what recommendations are made about pressure ulcer prevention and treatment at home, setting these in the context of safeguarding, and assessing what lessons may be learned by considering them as a group. This analysis is presented at a time of increased interest of the risks of pressure ulcers among frail and very ill populations; and debates about the interface of neglect and safeguarding systems.

Identification of SCRs from England where the person who died or who was harmed had been suffering from pressure ulcers or their synonyms in their home; termed home acquired pressure ulcers. Narrative and textual analysis of documents summarising the reports was undertaken to explore the reviews’ observations and recommendations. The main circumstances, recommendations and common themes were identified.

The authors located 18 relevant SCRs, one of which was a case summary and two SARs covering pressure ulcers that had been acquired or worsened when the individual was living at home. Most of these inquired into the individual’s circumstances, their acceptance of care and support, the actions of others in their family or professionals, and the events leading up to the death or harm. Failures to have followed guidance were noted among professionals, and problems within wider health and care systems were identified. Recommendations include calls for greater training on pressure ulcers for home care workers, but also greater risk communication and better adherence to clinical guidelines. A small number focus on neglect by family members, others on self-neglect, including some vulnerable adults’ lack of capacity to care for themselves or to access help. In some SCRs the presence of a pressure ulcer is only mentioned circumstantially.

The value of this documentary analysis is that it draws on case examples and scrutiny at local level. Future research could consider the related findings of SARs as they emerge, similar documents from the rest of the UK, and international perspectives

This analysis highlights the multitude of complex social and health situations that gives rise to pressure ulcers among people living at home. Several SCRs observe problems in the wider communications with and between health and care providers. Nonetheless poor care quality and negligence are reported in some SCRs. Cases of self-neglect give rise to challenging practice situations. While practices and policies about poor quality care and safeguarding in the form of prevention of wilful neglect are emerging, they often relate to hospital and care home settings. Preventing and treating pressure ulcers may be part of safeguarding in its broadest sense but raises the question of whether training, expertise and support on this subject or wider self-neglect and neglect by others are sufficiently robust for home care workers and community-based professionals.

The value of having a set of SCRs is that they lend themselves to analysis and comparison. This analysis is the first to focus on home acquired pressure ulcers and to address wider considerations related to safeguarding policy and practice. Pressure ulcers feature in several SCRs either as contextual information about the vulnerable adults’ health-status or as indications of poor care. The potential value of examining home acquired pressure ulcers as a key line of enquiry is that they are “visible” in the system, with consensus about what they are, how to measure them and what is optimal care and treatment. In the new Care Act 2014 context, they may still feature in safeguarding inquiries as symptoms of failings in systems or of personal culpability for poor care. Learning from them may be of interest to other parts of the UK.

This paper concerns the fall‐out from a TV programme which exposed the arbitrariness of cruelty at a private hospital that purported to provide assessment, treatment and rehabilitation to adults with learning disabilities, autism and mental health problems. The paper seeks to address the issues involved.

It describes the principal findings of a Serious Case Review which was commissioned after the TV broadcast, and outlines some of the activities designed to reduce the likelihood of such abuses recurring.

From policy, commissioning, regulation, management, service design and practice perspectives, events at Winterbourne View Hospital highlight a gulf between professionals, professionals and their organisations, and leadership shortcomings.

The English government responded promptly and encouragingly to the wretched circumstances of patients at Winterbourne View Hospital with a “Timetable of Actions”. The Serious Case Review which was commissioned after the TV broadcast contributed to the growing scepticism of “out of sight, out of mind” placements. It covered wide‐ranging territory.

The purpose of this paper is to report and discuss the findings of a thematic analysis from a survey of 114 serious case review (SCR) executive summaries in adult safeguarding. The Care Act 2014 (Section 44) makes the establishment of Safeguarding Adults Boards a statutory requirement. One of their responsibilities/functions is to undertake Safeguarding Adults Reviews (SAR-previously known as SCRs). They must also publish an annual report which includes the recommendations and actions from these SAR’s. This paper draws attention to the potential of SCR as national learning materials, and offers recommendations for strengthening the scope for interpretation in practice.

This paper maps the findings and recommendations from 114 SCRs undertaken in England and Wales between 2000 and 2012. It then identifies the dominant themes and universal lessons to emerge, and makes suggestions for the improvement of learning.

The demographic profile of SCRs bore some correlation to UK prevalence reports on perpetrator characteristics, but there was variance in relation to victim characteristics, where people with mental illness were the subject of SCRs with a level of frequency that does not mirror the prevalence of mental illness in reported abuse in the UK. The thematic analysis of conclusions and recommendations identified that these could be categorised as either idiosyncratic or bureaucratic.

The quality and quantity of information contained within the various SCR executive summary reports collated evidenced the lack of consistency/standardisation. Consequently, the analysis of demographic characteristics from these reports was compromised by incomplete data. In order to strengthen the scope of interpretation and understanding from future SARs to inform wider learning within the safeguarding community some national collation and standardisation is necessary.

This paper offers an analysis of the demographic profile and common themes emerging from an examination of the largest survey of SCR executive summaries reported on in the UK so far.

The purpose of this study is to assess, since the 2006 Fraud Review, recommendations, strategies and consequential organisational and other changes at national, regional and local levels relating to fraud, using the Northeast as a case study. It also notes that implementation may have been influenced by institutional changes and related emerging governmental policy agendas and institutional changes relating to organised crime, terrorism and cybercrime.

The research for the paper was undertaken by desk reviews of primary and secondary material. The paper also involved face-to-face interviews with personnel from the regional fraud unit and the three North-east police forces’ fraud units. The interviews were semi-structured and were conducted on grounds of anonymity for the personnel and the forces involved, with a focus on trends and issues. The personnel were invited to comment on a draft of the paper in terms of accuracy of the information they provided; no revisions or additions were proposed. Interpretation of that information is the sole responsibility of the author.

The paper finds that, despite the decade since the Fraud Review, issues of effectiveness or relevance of national fraud strategies, absence of incentives and identifiable benefits and continuous influence of competing agendas on police priorities continue to marginalise fraud as a mainstream police function and limit the level of resource committed to what also continues to be a rising area of criminality.

The research looks at the recommendations, strategies and consequential organisational and other changes at national, regional and local levels through implementation by four policing units in the North-east. It also notes that implementation may have been influenced by institutional changes and related emerging governmental policy agendas and institutional changes relating to organised crime, terrorism and cybercrime. While the research is limited in that, it draws on the experience of three local and one regional fraud unit; its findings support further research about the implementation of strategies and agendas in practice on the ground.

The research validates many of the findings by Her Majesty’s Inspectorate of Constabulary (HMIC) and supports the need to review national strategies to ensure effective implementation at local level for what also continues to be a rising area of criminality.

The research raises important issues concerning public concern over fraud where majority of frauds are of high volume, low value with low levels of recovery and usually targeted at individuals but where the policing responses are targeted elsewhere.

The research is the first study on the local implementation of national strategies on fraud and raises positive and less positive aspects of how far national strategies and intentions are addressed on the ground.

In recent years a variety of methods have been used to review cases where a vulnerable adult has died or been seriously harmed, the method chosen largely depending upon whether a single agency or multi-agency approach is required. Serious Case Reviews (SCRs) are more frequently used in cases requiring a multi-agency approach; however, their effectiveness in terms of being timely, value for money and a means of learning lessons has been questioned. Safeguarding Adult Boards (SAB) in the East Midlands have sought alternative means for reviewing some cases including the Significant Incident Learning Process (SILP). The purpose of this paper is to explore the experience of facilitating and evaluating a pilot SILP.

The paper explores the purpose and function of the SILP and then examines the process of facilitating a “live” event. A range of issues are explored including who should be involved, concerns around participation and working alongside criminal/police investigations and/or therapeutic intervention.

The findings are discussed and highlight the need for skilled, independent facilitators and robust “ground rules”. The paper evaluates the process and makes recommendations for further use of SILP.

This paper explores a new approach to reviewing cases previously reviewed using SCR, as such it will be of interest to all agencies and organisations represented on SAB. The evaluation of the SILP found it to be favourable in comparison with SCRs in terms of cost, being a process that can be completed within three months of an incident occurring and in terms of timely dissemination of lessons learned.

The purpose of this paper is to update the core data set of self-neglect safeguarding adult reviews (SARs) and accompanying thematic analysis, and to address the challenge of change, exploring the necessary components beyond an action plan to ensure that findings and recommendations are embedded in policy and practice.

Further published reviews are added to the core data set from the websites of Safeguarding Adults Boards (SABs). Thematic analysis is updated using the four domains employed previously. The repetitive nature of the findings prompts questions about how to embed policy and practice change, to ensure impactful use of learning from SARs. A framework for taking forward an action plan derived from an SAR findings and recommendations is presented.

Familiar, even repetitive findings emerge once again from the thematic analysis. This level of analysis enables an understanding of both local geography and the national legal, policy and financial climate within which it sits. Such learning is valuable in itself, contributing to the evidence base of what good practice with adults who self-neglect looks like. However, to avoid the accusation that lessons are not learned, something more than a straightforward action plan to implement the recommendations is necessary. A framework is conceptualised for a strategic and longer-term approach to embedding policy and practice change.

There is still no national database of reviews commissioned by SABs so the data set reported here might be incomplete. The Care Act 2014 does not require publication of reports but only a summary of findings and recommendations in SAB annual reports. This makes learning for service improvement challenging. Reading the reviews reported here enables conclusions to be reached about issues to address locally and nationally to transform adult safeguarding policy and practice.

Answering the question “how to create sustainable change” is a significant challenge for SARs. A framework is presented here, drawn from research on change management and learning from the review process itself. The critique of serious case reviews challenges those now engaged in SARs to reflect on how transformational change can be achieved to improve the quality of adult safeguarding policy and practice.

The paper extends the thematic analysis of available reviews that focus on work with adults who self-neglect, further building on the evidence base for practice. The paper also contributes new perspectives to the process of following up SARs by using the findings and recommendations systematically within a framework designed to embed change in policy and practice.

The purpose of this paper is to report the main themes identified into the Serious Case Review (SCR) produced by Surrey Safeguarding Adults Board (SSAB) regarding the suicide of Mrs A in January 2013.

A case study approach is used to examine the SCR. The paper links the findings of the SCR with the broader literature, which has examined the experiences of witnesses and complainants in cases of sexual violence.

The report emphasises that support for witnesses in historic sexual assault cases has improved but there are still significant gaps in provision. In particular, the systems need to support witnesses for longer after giving evidence. Mental health services need to be more aware of the potential impact of Court cases on victims of sexual violence. The case also highlights the potentially devastating impact of the media reporting of evidence given by victims in rape cases.

The authors hope that a wider consideration of the circumstances of this case will lead to a greater focus on the needs of victims in cases of historic rape and other sexual assault cases. The SCR highlights that the provision of support for women giving evidence in sexual abuse cases is patchy. Such cases raise very serious ethical issues including the question of how to use the special measures that exist to support vulnerable or intimidated witnesses.

The paper brings together a number of themes in the wider literature and links them to current practice. It also uses a case study approach to exploring the implications for women, in cases of historical sexual abuse, of giving evidence in Court proceedings.

This article examines the value of the concept of significant harm some 20 years after its introduction in the Children Act 1989. It introduces the concept of significant harm and then discusses the profile of children and families in care proceedings, the decision‐making process, the interpretation of significant harm in case law, ‘panic’ and its impact on patterns of referrals for case proceedings, and the issue of resources. An alternative model of the problem‐solving court is outlined. It is suggested that ‘significant harm’ has largely stood the test of time. However, the absence of a clear operational definition is both its strength and its weakness. It allows necessary professional discretion but is vulnerable to external pressures affecting its interpretation. A more confident workforce and sufficient resources are required, but the future role of the court and compulsory care is more contentious. The problem‐solving court model may offer a helpful way forward for the scrutiny of significant harm.

This article is an extended version of an ‘experts’ briefing' commissioned to inform senior child welfare managers in English local authorities and voluntary agencies about the available evidence to inform the provision of effective services in complex child protection cases. It starts by noting how differences in the approach to service provision in different jurisdictions affect both the nature of research conducted and its transferability across national boundaries. It then summarises the characteristics both of parents who are likely to maltreat their children and also of the children most likely to be maltreated. The factors that make some families ‘hard to engage’ or ‘hard to help/change’ are then discussed, as are the essential elements of effective professional practice in child protection. Particular attention is paid to effective approaches to helping families and young people who are hard to identify or engage.

A role available to adult protection committees is the consideration of local issues and making recommendations to promote protection locally. While policy development in health and social care has been the result, at times, of national inquiries, local inquiries also provide valuable opportunities to explore issues, to reflect and to learn. This article considers the processes through which local inquiries or reviews may be developed.